Curricular Processes as Practice: The Emergence of Excellence in a Medical School

This thesis deals with two related questions. The first relates to a critical inquiry into the processes of curriculum creation and formation within a medical school which has undergone a significant curriculum revision. I explore the notion that such processes can be understood as a form of practice in which the relationship between content and process is held together by what is explored in the thesis as an indivisible, paradoxical tension. Exploring curriculum as a kind of process is a novel approach in a school steeped in the traditions of the natural sciences. The common metaphors for curriculum in this setting refer to blueprints, models, behavioural competencies and objective standards. These are all founded on the belief in an objective observer who can maintain some form of distance between themselves and the subject in question. Issues of method are, therefore, central to my explorations of how we might, instead, locate curriculum in social processes and acts of evaluation involving power relations, conflict and the continuous negotiation of how it is we work together. The paradox of process and content in this way of understanding is that participants in curricular practice are simultaneously forming and being formed by their participation. In this way of thinking, it makes no sense to say one can either “step back” to “reflect” on their participation or that there is a way to approach participation “objectively.” The other question I address in this thesis has to do with the emergence of excellence. By emergence, I refer to thinking in the complexity sciences which attempts to explain phenomena which have a coherence which cannot be planned for or known in advance. “Excellence” is a kind of idealization which has no meaning until it is taken up and “functionalized” within specific settings and situations. In the setting of participating in curriculum formation, excellence may be understood as one possible outcome of persisting engagement and continuous inquiry which itself influences the ongoing conversation of how excellence is recognized and understood. In other words, excellence emerges in social processes as a theme simultaneously shaping and being shaped by curricular practice. This research was initiated as a result of a mandate to establish a program which could demonstrate excellence in the area of relationships in health care. The magnitude of this mandate felt overwhelming at the time and raised a lot of anxiety. I found that the traditional thinking regarding participation in organizational change processes (which, within my setting, could be understood as “set your goal and work backwards”) did not satisfactorily account for the uncertainties and surprises of working with colleagues to create something new. The method of inquiry can be read as another example of a process / content paradox through which my findings regarding curriculum and excellence emerged. This method involved taking narratives from my experience as an educator and clinician and a participant in varied forms of curricular processes and inquiring into them further by both locating them within relevant discourses from sociology, medical education and organizational studies and also sharing them with peers in my doctoral program as well as colleagues from my local setting. This method led to an inquiry and series of findings which was substantively different from my starting point. This movement in thinking offers another demonstration of an emergent methodology in which original findings are “discovered” through the course of inquiry. These findings continue to affect my practice and my approach to inquiry within the setting of medical education. The original contributions to thinking in medical education occur in several ways. One is in the demonstration of a research method which takes my own original experience seriously and seeks to challenge taken for granted assumptions about a separation of process and content, instead exploring the implications of understanding these in a relation of paradox. By locating my work within social processes of engagement and recognition, I explore the possibility that excellence can also be understood as an emergent property of interaction which is under continuous negotiation which itself forms the basis for further recognition and exploration of “excellence.” The social processes which shape and are shaped by “excellence” are fundamental to the practice of curriculum itself. Both curricula and “excellence” emerge within the interactions of people with a stake in the desired outcomes as the product of continued involvement and consideration of ongoing experience. Finally, a process view of medical education is presented as a contribution to understanding the work of training physicians who are comfortable with the uncertainties and contingencies involved in the humane care of their patients